Request to Attend Seminar, Workshop or Conference

Complete and submit all of the following:

1. This form Request to Attend Seminar, Workshop or Conference
2. Attach course registration information or link to website for registration
3. Attach Agenda and objectives for this course.

Name: Nancy Mathis

Home or Work Address for Registration:7767 Elm Creek Blvd
City: Maple Grove
Zip: 55369
Work phone: 7634168706
Cell phone: 7639136077
Special needs or requests (ie menu):
Membership (check one and enter number)x ASHA /
APTA /
Other:

AOTA/

Title of Conference/Meeting ASHA Convention

Sponsored By: ASHA- American Speech Hearing Association
Date(s) of Meeting Wednesday November 11th through Saturday November 14 2015
Location: Denver Colorado
Why are you asking to attend this conference?Increase knowledge in variety of areas
List 2 things you plan to learn from this course and will apply to your practice here at
Children'sCleft palate session, Motor speech session, iPad session, Neuroscience about
the brain and ASD.
How will this information benefit the department/organization? Learn how to better serve
all pts but in particular those children with cleft palate, motor speech disorders, and ASD.
Requested Expenses to be paid by Childrens Hospitals and Clinics of Minnesota
Tuition / Registration:
$ 425
Travel Expenses:
Lodging
$?
Meals
$?
Transportation
$?
Miscellaneous
$?
Total Anticipated Cost
$ 425
Anticipated Employee Expenses( if applicable)
Amount of tuition / conference fee paid by employee:
monies
Amount of travel expenses paid by employee:

$ $5 I have $420 left of my

$ all

Requested Time off - Please indicate number of hours

Paid Conference Time: 16
Additional PTO Time off: 0
Note: Should the employee resign within 6 months of course completion; the employee
will reimburse the department for all expenses incurred.

Signatures/ Approvals:
Employee _____________________________________________ Dated ____________
Manager ______________________________________________ Dated ____________